Abstract

To compare the outcomes of flexible ureterorenoscopy (F-URS) with extracorporeal shock wave lithotripsy (ESWL) for the treatment of upper or mid calyx kidney stones of 10 to 20 mm. A total of 174 patients with radioopaque solitary upper or mid calyx stones who underwent ESWL or F-URS with holmium:YAG laser were enrolled in this study. Each group treated with ESWL and F-URS for upper or mid calyx kidney stones were retrospectively compared in terms of retreatment and stone free rates, and complications. 87% (n = 94) of patients who underwent ESWL therapy was stone free at the end of 3rd month. This rate was 92% (n = 61) for patients of F-URS group (p = 0.270 p > 0.05). Retreatment was required in 12.9% of patients (n = 14) who underwent ESWL and these patients were referred to F-URS procedure after 3rd month radiologic investigations. The retreatment rate of cases who were operated with F-URS was 7.5% (n = 5) (p = 0.270 p > 0.05). Ureteral perforation (Clavien grade 3B) was occured in 3 patients (4.5%) who underwent F-URS. Fever (Clavien grade 1)was noted in 7 and 5 patients from ESWL and F-URS group, respectively (6.4% vs 7.5%) (p = 0.78 p > 0.05). F-URS and ESWL have similar outcomes for the treatment of upper or mid calyx renal stones of 10-20 mm. ESWL has the superiority of minimal invasiveness and avoiding of general anethesia. F-URS should be kept as the second teratment alternative for patients with upper or mid caliceal stones of 10-20 mm and reserved for cases with failure in ESWL.

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1

This report is a retrospective analysis of treatment results in 174 patients with middle and upper calyx stones measuring 10-20 mm. The two groups of patients had been treated either with SWL or flexible URS. How the patients were referred to the two treatment modalities is not mentioned, but the patients compared were obviously matched according to stone size, age, gender and BMI. Nevertheless there were 108 patients treated with SWL, but only 66 treated endoscopically.

It is of note that all SWL-sessions were carried out only by giving an injection of NSAID before the session. There was no other analgesics/sedatives or general anaesthesia and the lithotripter (Siemens Lithostar) thus seems to cause only mild discomfort. because the treatment was apparently not restricted because of pain.

By including patients with up to 2 mm large fragments, the success rate was 87% following SWL and 92% following URS. This means apparently a very small difference. Re-treatments were carried out in 13 and 8% of the patients, respectively. Complications were reported in 17% and 23%, in SWL and URS treated patients, respectively and with a slightly more severe pattern in the URS-treated patients.

In view of the similarities in success between the two methods it seems reasonable to recommend SWL as first line treatment for stones of this kind. This is also in line with the EAU recommendations. The advantage of SWL becomes even more obvious if an approximate stone treatment index STI [1] is calculated for the two modalities. By assuming a similar average stone composition, assumptions of the stone width and without exact information on the number of sessions in each group, STI was 6.2 for SWL and 4.0 for URS (High values are better!).

This report is a retrospective analysis of treatment results in 174 patients with middle and upper calyx stones measuring 10-20 mm. The two groups of patients had been treated either with SWL or flexible URS. How the patients were referred to the two treatment modalities is not mentioned, but the patients compared were obviously matched according to stone size, age, gender and BMI. Nevertheless there were 108 patients treated with SWL, but only 66 treated endoscopically.
It is of note that all SWL-sessions were carried out only by giving an injection of NSAID before the session. There was no other analgesics/sedatives or general anaesthesia and the lithotripter (Siemens Lithostar) thus seems to cause only mild discomfort. because the treatment was apparently not restricted because of pain.
By including patients with up to 2 mm large fragments, the success rate was 87% following SWL and 92% following URS. This means apparently a very small difference. Re-treatments were carried out in 13 and 8% of the patients, respectively. Complications were reported in 17% and 23%, in SWL and URS treated patients, respectively and with a slightly more severe pattern in the URS-treated patients.
In view of the similarities in success between the two methods it seems reasonable to recommend SWL as first line treatment for stones of this kind. This is also in line with the EAU recommendations. The advantage of SWL becomes even more obvious if an approximate stone treatment index STI [1] is calculated for the two modalities. By assuming a similar average stone composition, assumptions of the stone width and without exact information on the number of sessions in each group, STI was 6.2 for SWL and 4.0 for URS (High values are better!).
Reference.
1.Tiselius HG, Ringdén I. Stone treatment index: a mathematical summary of the procedure for removal of stones from the urinary tract. J Endourol. 2007 21:1261-1269.